CLINICAL HANDBOOK OF SCHIZOPHRENIA

198 III. SOMATIC TREATMENTCatatoniaECT is indicated for catatonia secondary to any etiopathology that is unresponsive totreatment with medication.Pretreatment EvaluationA comprehensive evaluation for patients undergoing ECT should include a complete psychiatrichistory, mental status examination, and medical/surgical history. The patient’sright- or left-handedness should be assessed to recognize the pattern of cerebral hemisphericdominance. A physical examination should be performed, and laboratory tests,including electrolytes, hemogram, electrocardiogram (ECG), computed tomography(CT) or magnetic resonance imaging (MRI) of the head, and a chest X-ray, should be obtained.The patient’s current and prior pharmacotherapy should be reviewed because of possibleinteractions between medications, anesthetic medications, and ECT. For example,lithium taken during ECT treatment may increase post-ECT incidence of delirium or confusion.Benzodiazepine use can reduce the seizure duration and should be tapered or discontinued.Prior to beginning a course of acute ECT, monoamine oxidase inhibitors(MAOIs) have been found to result in drug–drug interactions with anesthetic agents andshould be discontinued. Antipsychotic medications have a synergistic effect with ECT,except reserpine, which can lead to sudden death in certain cases. Anticonvulsant medicationsinterfere with the induction of seizure activity and should be tapered or discontinued.Tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs)are usually safe to use with ECT. The patient should not take anything by mouth for 8hours before the ECT treatment.ECT ProcedureThe patient is closely monitored (i.e., vital signs, ECG recording, pulse oximetry) duringthe ECT procedure. A short-acting barbiturate, such as methohexital, is administered intravenously(IV) at a dose of 1 mg/kg body weight, followed by succinylcholine IV at thedose of 0.75–1.5 mg/kg body weight. Methohexital is typically preferred over other anestheticssuch as etomidate and alfentanil which can increase—or thiopental, propofol,thiamylal, midazolam, and lorazepam, which can decrease—the duration of ECT-inducedseizure activity (relative to methohexital or saline, respectively) (Zhengnian & White,2002). The patient is ventilated with 100% oxygen during the procedure.After the scalp is properly prepared by cleaning the skin, the electrodes are placed.For safety, a bite block is placed in the patient’s mouth to avoid tongue bite. Seizure activityis monitored by electroencephalography (EEG), and motor movements are observedon the isolated arm or foot. Upon completion of the ECT treatment, the patient is transportedto the recovery room, where he or she is continuously monitored until he or sheattains complete recovery. The ECT procedure takes approximately 15 minutes and isfollowed by a recovery time of 20–30 minutes. The patient is generally allowed to eatwithin an hour of recovery.Electrode PlacementThe three different methods of electrode placement in ECT include bitemporal placement,bifrontal placement, and right unilateral placement (see Figure 20.1).